Monday, April 24, 2006

Oxycodone meta-analysis; Patients' treatment preferences over time; Physician end of life decision-making

A few articles from the current Archives of Internal Medicine...

There's a meta-analysis of trials involving oxycodone for cancer pain. The authors looked at the 4 (ahem) randomized, controlled trials involving oxycodone for cancer pain--3 compared oxycodone to morphine and one with hydromorphone. My gloss on their findings: no evidence of superiority of any of these agents over the other with regards to analgesic efficacy & side effect profile; side effects were common and problematic in all the trials and on all the agents; the studies support the idea that oxycodone is moderately more potent than morphine.

There's also a prospective study following patients' health and health care preferences over time. It is based on prospective interviews with ~200 elderly, community-dwelling people with severe, chronic illnesses (cancer, CHF, COPD) and some restrictions in their activities of daily living. The subjects were interviewed regularly for a couple of years and were asked to state the acceptability of a medical treatment if it would result in certain outcomes (mild functional impairment; severe disability; ongoing pain; severe cognitive impairment). One of the major findings were that severe cognitive impairment (inability to recognize family members) was across the board unacceptable to the vast majority of subjects (meaning that they stated they'd rather not receive medical treatment if that was the best outcome). Not surprising. The other major finding was that for those patients whose health status declined during the study severe disability became a more acceptable outcome. That is--as the subjects themselves became more disabled, disability became more acceptable. While this too isn't surprising and consistent with earlier studies, the authors discuss this as if it strikes a grave blow to advance directives because, essentially, people change. Not wanting to belabor this, I'll refer interested readers to previous comments on advance directives for my response to this.

And there's also a survey of European and Australian physicians' end of life decision making. It is one of those scenario based surveys (metastatic cancer patient, lacks decision-making capacity, 2 weeks to live, in pain, family asks you to terminally sedate them--would you do it?) whose results are too complex to summarize here. I am always skeptical of these surveys and wonder if they measure anything that's clinically meaningful. That being said, it's always interesting to look at them and see how many of the docs give what I consider shocking or obnoxious responses (4% of the Italian respondents said they'd give chemotherapy to a 'subcomatose' bedridden patient with 2 weeks to live even if this contravened their advance directive; 12% of the Danish respondents said they'd 'euthanize'--by their own [the docs', not the patient's] initiative--a conscious, communicative--albeit symptomatic and bedridden--cancer patient with 2 weeks to live). This last result in particular is so obnoxious that it makes me skeptical, again, of the clinical relevance of this type of research.

And finally there's also a brief survey article indicating African-Americans generally have less trust in health care providers than whites. Not strictly palliative care-related, but nonetheless of supreme importance for those of us for whom physician-patient trust is the bedrock of our practice.

All of these articles have cemented for me my impression that Archives publishes the highest number of palliative care-relevant articles of any of the major, general journals. Not necessarily the highest quality articles (I have no strong opinions on that), but definitely the most.

And one more thing:
For those readers who are interested in pain policy issues & the DEA, etc.--there's been a recent comment on a prior post that has several interesting links. Thanks, Dr. Alex DeLuca.

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